Outbreaks of different viral etiologies amidst COVID-19 pandemic

The COVID-19 pandemic has severely affected public health system and surveillance of other communicable diseases across the globe. The lockdown, travel constraints and COVID phobia turned down the number of people with illness visiting to the clinics or hospitals. Besides this, the heavy workload of SARS-CoV-2 diagnosis has led to the reduction in differential diagnosis of other diseases. Consequently, it added to the underlying burden of many diseases which remained under-diagnosed. Amidst the pandemic, the rise of emerging and re-emerging infectious diseases was observed worldwide and reported to the World Health Organization i.e., Crimean Congo Hemorrhagic Fever (2022, Iraq;2021 India), Nipah virus (2021, India), Zika virus (2021, India), and H5N1 influenza (2021, India), Monkeypox (2022, multicountry outbreak), Ebola virus disease (2022, DRC, Uganda;2021, DRC, Guinea;2020, DRC), Marburg (2022, Ghana;2021, Guinea), Yellow fever (2022, Uganda, Kenya, West and Central Africa;2021, Ghana, Venezuela, Nigeria;2020, Senegal, Guinea, Nigeria, Gabon;2020, Ethiopia, Sudan, Uganda), Dengue (2022, Nepal, Pakistan, Sao Tome, Temor-Leste;2021, Pakistan), Middle east respiratory syndrome coronavirus (2022, Oman, Qatar;2021, Saudi Arabia, UAE;2020, Saudi Arabia, UAE), Rift valley fever (2021, Kenya;2020, Mauritania), wild poliovirus type 1 (2022, Mozambique), Lassa fever (2022, Guinea, Togo, Nigeria;2020, Nigeria), Avian Influenza (H3N8) (2022, China), Avian Influenza (H5N1) (2022, USA), H10N3 influenza (2021, China), Hepatitis E virus (2022, Sudan), Measles (2022, Malawi, Afghanistan;2020, Burundi, Mexico), Mayaro virus disease (2020, French Guiana), Oropouche virus disease (2020, French Guiana). All these diseases were associated with high morbidity and burdened the public health system during the COVID-19 pandemic. During this critical public health menace, majority of the laboratory workforce was mobilized to the SARS-CoV-2 diagnosis. This has limited the surveillance efforts that likely led to under diagnosis and under-detection of many infectious pathogens. Lockdowns and travel limitations also put a hold on human and animal surveillance studies to assess the prevalence of these zoonotic viruses. In addition, lack of supplies and laboratory personnel and an overburdened workforce negatively impacted differential diagnosis of the diseases. This is especially critical given the common symptoms between COVID-19 and other pathogens causing respiratory illnesses. Additionally, the vaccination programs against various vaccine preventable diseases were also hampered which might have added to the disease burden. Despite these challenges, the world is better prepared to detect and respond to emerging/re-emerging pathogens. India now has more than 3000 COVID-19 diagnostic laboratories and an enhanced hospital infrastructure. In addition, mobile BSL-3 facilities are being validated for onsite sampling and testing in remote areas during outbreak situations and surveillance activities. This will undoubtedly be valuable as the COVID-19 pandemic evolves as well as during future outbreaks and epidemics. In conclusion, an increase in the emergence and re-emergence of viruses demonstrates that other infectious diseases have been neglected during the COVID-19 pandemic. Lessons learned from the infrastructure strengthening, collaborations with multiple stakeholders, increased laboratory and manufacturing capacity, large-scale COVID-19 surveillance, extensive network for laboratory diagnosis, and intervention strategies can be implemented to provide quick, concerted responses against the future threats associated with other zoonotic pathogens.

Evaluation of Crimean-Congo Hemorrhagic Fever Cases During the COVID-19 Pandemic Period

Introduction: Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease that progresses with fever and bleeding and is endemic in our region. In this study, we aimed to determine the symptoms, transmission routes and risk factors in CCHF patients who have similar clinical features with COVID-19, and to investigate the relationship between CCHF cases and COVID-19 restrictions in our region where CCHF is endemic. Materials and Methods: One hundred fifty-nine patients diagnosed with CCHF in the infectious diseases and clinical microbiology clinic between April 2021 and September 2021 were included in the study. A questionnaire consisting of a set of questions was filled in for patients diagnosed with CCHF, in which demographic data, admission complaints, risk factors and habits during the COVID-19 pandemic were evaluated. Results: The mean age of the 159 CCHF patients included in the study was 50.9 +/- 18.5 years and 59.7% were male. The most frequently reported complaints by the patients were fatigue (94.5%), muscle-joint pain (79.9%) and fever (74.2%). During the disease period, COVID-19 was suspected in 62.3% of them, PCR test was applied to all of them, and the result was positive in only one patient. There was no change of residence of the patients during the illness period. There was no significant increase in the population of the residence area or the frequency of visits due to the pandemic. The number of patients who reported an increase in the number of ticks in their environment was 44 (27.8%). It was determined that there was no significant increase in the number of activities such as visiting rural areas or having a picnic due to the COVID-19 pandemic. Only 32.2% of patients engaged in animal husbandry or field work reported an increase in the frequency of these jobs compared to the pre-pandemic period. Conclusion: The reason for the increase in the number of CCHF cases in our center was not associated with the increase in the frequency of visits to rural areas or the change of residence during the COVID-19 pandemic period.

Increased Mortality with Co-existence of Crimean-Congo Hemorrhagic Fever and COVID-19

Crimean-Congo hemorrhagic fever (CCHF) is an acute viral disease with fever and bleeding caused by a tick-borne virus belonging to the Bunyaviridae family. Coronavirus disease-2019 (COVID-19) is a novel disease caused by Severe Acute Respiratory Syndrome Coronavirus Type 2, which can lead to acute respiratory distress syndrome (ARDS). Here, we present a case with CCHF and COVID-19 co-infection to draw attention to the increased mortality in co-infection cases. A 77-year-old female patient with known hypertension was admitted to the emergency department with complaints of fever, nausea, vomiting, diarrhea, and myalgia for two days. There was no history of tick bite or contact with a patient with COVID-19. Current anamnesis and clinical and laboratory findings pre-diagnose the patient with CCHF, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura, leading to a ward admission. Crimean-Congo hemorrhagic fever was diagnosed after receiving a positive CCHF immunoglobulin M (indirect fluorescent antibody) result. A nasopharyngeal swab sample for COVID-19 real-time polymerase time reaction was sent due to a continuous fever and the development of shortness of breath on day three of hospitalization, which revealed positive results;thus, the patient was started on favipiravir treatment. The patient was transferred to the intensive care unit on day four due to increased oxygen demand and ARDS diagnosis. The patient died due to respiratory failure on the seventh day of hospitalization. COVID-19-related ARDS that overlapped on top of CCHF caused her to develop a cytokine storm and died despite her clinical parameter improvement due to CCHF. Crimean-Congo hemorrhagic fever and COVID-19 symptoms or findings can be confused because of their similarities, but the possibility of being seen together should not be overlooked. Concurrently, some similarities in the pathogenesis of these two diseases suggest that co-infection may worsen the clinical course;hence, new studies are needed on this subject.

An evaluation of the laboratory and clinical data of the Crimean-Congo hemorrhagic fever patients during the COVID-19 pandemic

In this study, the purpose was to investigate the demographic, laboratory, and clinical characteristics of the Crimean-Congo Hemorrhagic Fever (CCHF) cases that were treated in our hospital during the Coronavirus disease-2019 (COVID-19) pandemic. It was also investigated whether the patients hospitalized with a provisional diagnosis of CCHF who tested negative for CCHF PCR were infected with COVID-19. In our study, data (epidemiological, clinical, laboratory, prognosis) from 38 patients diagnosed with CCHF through reverse-transcriptase polymerase chain reaction (PCR) and viral-RNA and/or Immunoglobulin M antibodies using ELISA between May 2020 and November 2022 were investigated retrospectively. Of all the patients, 23 were CCHF PCR (+) and 15 were CCHF PCR (-).15 (65.2%) of PCR (+) patients and 9 (60%) of PCR (-) patients were engaged in farming. 65.2% of PCR (+) and 26.7% of PCR (-) patients presented with a history of tick bites. 21 (91.3%) of PCR (+) and 12 (80%) of PCR (-) patients had a history of rural living. Among the PCR (+) patients, 65.2%, 17.4%, and 17.4% received treatment for CCHF in 2022, 2021, and 2020 respectively. 87% of PCR (+) and 60% of PCR (-) patients were discharged after full recovery. The most common symptoms were fever, diffuse body ache, weakness, and headache. Significant differences were found between PCR (+) and PCR (-) patients in terms of leukocytes, LDH, INR, NEU, PLT, fibrinogen, and NLR values. 3 patients hospitalized with a provisional diagnosis of CCHF tested negative for CCHF PCR and positive for COVID-19 PCR. Thoracic CT, clinical, and laboratory findings of these patients showed no differences from the other patients. The possibility of misdiagnosis should be considered in CCHF and COVID-19 infections due to their similar symptoms and indications. Extensive multicentric studies need to be conducted to investigate the causes of the increased number of CCHF cases during the pandemic. © 2023 Ondokuz Mayis Universitesi. All rights reserved.

Summary of global surveillance data of infectious diseases in January 2023

In January 2023, a total of 64 infectious diseases were reported globally, affecting 235 countries and regions. Except for influenza, the top five infectious diseases affecting greatest number of countries and regions were COVID-19 (235), monkeypox (110), dengue fever (31), measles (27) and cholera (15). The top five infectious diseases with highest case fatality rates were Nipah virus disease (62.5%), Ebola virus disease (47.0%), Crimean-Congo haemorrhagic fever (37.5%), Lassa fever (15.1%) and West Nile fever (7.6%). The top five infectious diseases with greatest number of deaths were COVID-19, malaria, cholera, measles and dengue fever. The prevalent infectious diseases in Asia were COVID-19, cholera and dengue fever, the prevalent infectious diseases in Africa were COVID-19, cholera, yellow fever, Lassa fever, malaria and monkeypox, the prevalent infectious diseases in America were COVID-19, cholera, monkeypox, dengue fever and chikungunya fever, the prevalent infectious disease in Europe were COVID-19, monkeypox and invasive group A streptococcus infection.

Summary of global surveillance data of infectious diseases in December 2022

In December 2022, a total of 68 infectious diseases were reported globally, affecting 235 countries and regions. Except for influenza, the top five infectious diseases affecting greatest number of countries and regions were COVID-19 (235), monkeypox (110), dengue fever (28), measles (27) and cholera (14). The top five infectious diseases with highest case fatality rates were Ebola virus disease (47.0%), Rift Valley fever (44.2%), Crimean-Congo haemorrhagic fever (40.0%), Lassa fever (17.6%) and West Nile fever (7.6%). The top five infectious diseases with greatest number of deaths were COVID-19, malaria, cholera, dengue fever and measles. The prevalent infectious diseases in Asia were COVID-19, cholera and dengue fever, the prevalent infectious diseases in Africa were COVID-19, cholera, yellow fever, Lassa fever, monkeypox, malaria and measles, the prevalent infectious diseases in America were COVID-19, cholera, monkeypox, dengue fever and chikungunya fever, the prevalent infectious disease in Europe were COVID-19, monkeypox and invasive group A streptococcus infection.

Evaluation of Crimean-Congo Hemorrhagic Fever Cases During the COVID-19 Pandemic Period.

Introduction: Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease that progresses with fever and bleeding and is endemic in our region. In this study, we aimed to determine the symptoms, transmission routes and risk factors in CCHF patients who have similar clinical features with COVID-19, and to investigate the relationship between CCHF cases and COVID-19 restrictions in our region where CCHF is endemic. Material(s) and Method(s): One hundred fifty-nine patients diagnosed with CCHF in the infectious diseases and clinical microbiology clinic between April 2021 and September 2021 were included in the study. A questionnaire consisting of a set of questions was filled in for patients diagnosed with CCHF, in which demographic data, admission complaints, risk factors and habits during the COVID-19 pandemic were evaluated. Result(s): The mean age of the 159 CCHF patients included in the study was 50.9 +/- 18.5 years and 59.7% were male. The most frequently reported complaints by the patients were fatigue (94.5%), muscle-joint pain (79.9%) and fever (74.2%). During the disease period, COVID-19 was suspected in 62.3% of them, PCR test was applied to all of them, and the result was positive in only one patient. There was no change of residence of the patients during the illness period. There was no significant increase in the population of the residence area or the frequency of visits due to the pandemic. The number of patients who reported an increase in the number of ticks in their environment was 44 (27.8%). It was determined that there was no significant increase in the number of activities such as visiting rural areas or having a picnic due to the COVID-19 pandemic. Only 32.2% of patients engaged in animal husbandry or field work reported an increase in the frequency of these jobs compared to the pre-pandemic period. Conclusion(s): The reason for the increase in the number of CCHF cases in our center was not associated with the increase in the frequency of visits to rural areas or the change of residence during the COVID-19 pandemic period.Copyright © Telif Hakki 2022 Flora.

Evaluation of Crimean-Congo Hemorrhagic Fever Cases During the COVID-19 Pandemic Period

Introduction: Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease that progresses with fever and bleeding and is endemic in our region. In this study, we aimed to determine the symptoms, transmission routes and risk factors in CCHF patients who have similar clinical features with COVID-19, and to investigate the relationship between CCHF cases and COVID-19 restrictions in our region where CCHF is endemic. Materials and Methods: One hundred fifty-nine patients diagnosed with CCHF in the infectious diseases and clinical microbiology clinic between April 2021 and September 2021 were included in the study. A questionnaire consisting of a set of questions was filled in for patients diagnosed with CCHF, in which demographic data, admission complaints, risk factors and habits during the COVID-19 pandemic were evaluated. Results: The mean age of the 159 CCHF patients included in the study was 50.9 ± 18.5 years and 59.7% were male. The most frequently reported complaints by the patients were fatigue (94.5%), muscle-joint pain (79.9%) and fever (74.2%). During the disease period, COVID-19 was suspected in 62.3% of them, PCR test was applied to all of them, and the result was positive in only one patient. There was no change of residence of the patients during the illness period. There was no significant increase in the population of the residence area or the frequency of visits due to the pandemic. The number of patients who reported an increase in the number of ticks in their environment was 44 (27.8%). It was determined that there was no significant increase in the number of activities such as visiting rural areas or having a picnic due to the COVID-19 pandemic. Only 32.2% of patients engaged in animal husbandry or field work reported an increase in the frequency of these jobs compared to the pre-pandemic period. Conclusion: The reason for the increase in the number of CCHF cases in our center was not associated with the increase in the frequency of visits to rural areas or the change of residence during the COVID-19 pandemic period.

Impact of Three Outbreaks on Mpox Prevention Program in Iraq: Lessons and Recommendations

The Covid-19 pandemic has strained an already fragile Iraqi healthcare system. Globally, the pandemic affected the emergence and re-emergence of infectious illnesses. Despite the Covid-19 pandemic, the Iraqi healthcare system was further exhausted when the country reported cases of Crimean Congo Hemorrhagic Fever and Cholera. Mpox is a zoonotic viral disease caused by the MPOX virus. In Iraq, as all resources are directed towards these three outbreaks, Mpox becomes extremely negligible. Failure to prevent the spread of this disease will have a catastrophic effect on the Iraqi healthcare system. Efforts should be made to increase population awareness regarding transmission routes and symptoms of Mpox. Training programs should be provided to healthcare workers to distinguish Mpox from other rash illnesses concisely. Effective surveillance programs and providing diagnostic tools to detect unknown or suspected cases should be the priority of the health authorities. Lessons must be learned from these three outbreaks.

Changing Disease Course of Crimean-Congo Hemorrhagic Fever in Children, Turkey.

Crimean-Congo hemorrhagic fever (CCHF), endemic in certain regions of the world, is listed as a priority disease with pandemic potential. Since CCHF was first identified in Turkey, children have been known to experience milder disease than adults. However, during the COVID-19 pandemic, we observed an unusually severe disease course, including hemophagocytic lymphohistiocytosis (HLH). We examined cytokine/chemokine profiles of 9/12 case-patients compared with healthy controls at 3 time intervals. Interferon pathway-related cytokines/chemokines, including interleukin (IL) 18, macrophage inflammatory protein 3α, and IL-33, were elevated, but tumor necrosis factor-α, IL-6, CXCL8 (formerly IL-8), and cytokines acting through C-C chemokine receptor 2 and CCR5 were lower among case-patients than controls. Interferon pathway activation and cytokines/chemokines acting through CCR2 and CCR5 improved health results among children with severe CCHF. Children can experience severe CCHF, including HLH, and HLH secondary to CCHF can be successfully treated with intravenous immunoglobulin and steroid therapy.

Crimean-Congo hemorrhagic fever outbreak in Pakistan, 2022: A warning bell amidst unprecedented floods and COVID 19 pandemic.

Crimean-Congo hemorrhagic fever (CCHF) is an infection caused by a tick-borne virus (genus: Nairovirus, family: Bunyaviridae). The most important vector for CCHF is the ixodid tick. Along with tick bite, direct contact with the virus-affected animal is responsible for its spread. Pakistan witnessed its first case of CCHF in 1976 and has been a major victim of CCHF for years, but spikes in cases are seen after Eid-ul-Adha, an Islamic festival involving the sacrifice of cattle. The disease, in particular, is common among butchers, veterinarians, and livestock workers. From the start of this year till June 22, 2022, a total of four cases have been reported across the country. Pakistan faces major challenges in combating CCHF every year due to its specific geographical position and a majority of the population being involved with animal husbandry. There is no approved vaccine for its prevention. All these factors contribute to the burden on the already weakened healthcare system of Pakistan. Strict actions should be taken to contain the spread of the disease. The need of the hour is to engage the general population, raise awareness, and develop policies to ensure disease surveillance. This should be accompanied by fostering collaboration among animal and human health departments for efficient communication and early intervention. The focus should be on medical research to find an efficacious treatment and prophylaxis for the CCHF virus, which will be the cornerstone of future CCHF prevention and control strategies.

Dengue Fever, Crimean-Congo Hemorrhagic Fever, and COVID-19 Triple Co-infection: Out of the Frying Pan Into the Fire.

In developing countries, infectious diseases are thriving due to poor hygiene, inadequate public health infrastructure, and socio-cultural factors. Generally, infections are due to a single pathogen, but due to the shared risk factors for transmission, co-infections are not uncommon. The severity and outcome of infections are adversely affected by co-infection. Co-infections present as diagnostic and therapeutic enigmas because of the complex interaction between different pathogens involved and distorted host responses. The southeast Asian region, particularly Pakistan, is known for unique combinations of different infections. We present a distinctive case of triple co-infection of dengue virus, Crimean-Congo hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. The index case was a 60-year-old gentleman who presented with fever, cough, shortness of breath, bruises, and hemoptysis. He had thrombocytopenia, deranged liver and renal function, coagulopathy, and infiltrates in both lung fields. Subsequent investigations revealed a positive polymerase chain reaction for ribonucleic acid of dengue virus, Crimean-Congo Hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. He received supportive treatment including antibiotics, blood products, ribavirin, and supplemental oxygen. He developed multi-organ failure and succumbed to the triple co-infection. This case will act as a wake-up call for clinicians, public health authorities, and infectious disease specialists to plan before the volcano of co-infections erupts.

Summary of global surveillance data of infectious diseases in may 2022

In May 2022, a total of 66 infectious diseases were reported globally, affecting 233 countries and regions. Except for influenza, the top five infectious diseases affecting greatest number of countries and regions were COVID-19 (233), monkeypox (36), dengue fever (31), measles (24) and cholera (11). The top five infectious diseases with highest case fatality rates were Ebola virus disease (100.0%), Middle East Respiratory Syndrome (34.4%), Crimean-Congo hemorrhagic fever (22.2%), Lassa fever (19.8%) and monkeypox (4.0%). The top five infectious diseases with greatest number of deaths were COVID-19, malaria, cholera, dengue fever and measles. The prevalent infectious diseases in Asia were COVID-19, dengue fever and cholera, the prevalent infectious diseases in Africa were COVID-19, Ebola virus disease, cholera, yellow fever, Lassa fever, malaria and monkeypox, the prevalent infectious diseases in America were COVID-19, dengue fever, chikungunya fever and Zika virus disease, the prevalent infectious disease in Europe were COVID-19, monkeypox and acute hepatitis of unknown aetiology.

Crimean-Congo Hemorrhagic Fever Outbreak in Refugee Settlement during COVID-19 Pandemic, Uganda, April 2021.

Crimean-Congo hemorrhagic fever (CCHF) was detected in 2 refugees living in a refugee settlement in Kikuube district, Uganda. Investigations revealed a CCHF IgG seroprevalence of 71.3% (37/52) in goats within the refugee settlement. This finding highlights the need for a multisectoral approach to controlling CCHF in humans and animals in Uganda.

Plant-Derived Recombinant Vaccines against Zoonotic Viruses.

Emerging and re-emerging zoonotic diseases cause serious illness with billions of cases, and millions of deaths. The most effective way to restrict the spread of zoonotic viruses among humans and animals and prevent disease is vaccination. Recombinant proteins produced in plants offer an alternative approach for the development of safe, effective, inexpensive candidate vaccines. Current strategies are focused on the production of highly immunogenic structural proteins, which mimic the organizations of the native virion but lack the viral genetic material. These include chimeric viral peptides, subunit virus proteins, and virus-like particles (VLPs). The latter, with their ability to self-assemble and thus resemble the form of virus particles, are gaining traction among plant-based candidate vaccines against many infectious diseases. In this review, we summarized the main zoonotic diseases and followed the progress in using plant expression systems for the production of recombinant proteins and VLPs used in the development of plant-based vaccines against zoonotic viruses.

Summary of global surveillance data of infectious diseases in March 2022

In March 2022, a total of 63 infectious diseases were reported globally, affecting 230 countries and regions. Except for influenza, the top five infectious diseases affecting greatest number of countries and regions were COVID-19 (230), dengue fever (32), measles (29), chikungunya fever (10) and cholera (9). The top five infectious diseases with highest case fatality rates were Crimean-Congo haemorrhagic fever (33.3%), Rift Valley fever (20.0%), Lassa fever (18.6%), yellow fever (11.3%) and monkeypox (5.5%). The top five infectious diseases with greatest number of deaths were COVID-19, malaria, measles, cholera and Lassa fever. The prevalent infectious diseases in Asia were COVID-19 and dengue fever, the prevalent infectious diseases in Africa were COVID-19, cholera, yellow fever, Lassa fever, malaria, measles and poliomyelitis, the prevalent infectious diseases in America were COVID-19, dengue fever and chikungunya fever, the prevalent infectious disease in Europe was COVID-19.

Transcriptome dataset of six human pathogen RNA viruses generated by nanopore sequencing.

Long-read sequencing (LRS) approaches shed new light on the complexity of viral (Kakuk et al., 2021 [1]; Boldogkoi et al., 2019 [2]; Depledge et a., 2019 [3]), bacterial (Yan et al., 2018 [4]) and eukaryotic (Tilgner et al., 2014 [5]) transcriptomes. Emerging RNA viruses are zoonotic (Woolhouse et al., 2016 [6]) and create public health problems, e.g. influenza pandemic caused by H1N1 virus in (Fraser et al., 2009 [7]), as well as the current SARS-CoV-2 pandemic (Kim et al., 2020 [8]). In this study, we carried out nanopore sequencing for generating transcriptomic data valuable for structural and kinetic profiling of six important human pathogen RNA viruses, the H1N1 subtype of Influenza A virus (IVA), the Zika virus (ZIKV), the West Nile virus (WNV), the Crimean-Congo hemorrhagic fever virus (CCHFV), the Coxsackievirus [group B serotype 5 (CVB5)] and the Vesicular stomatitis Indiana virus (VSIV), and the response of host cells upon viral infection. The raw sequencing data were filtered during basecalling and only high quality reads (Qscore ≥ 7) were mapped to the appropriate viral and host genomes. Length distribution of sequencing reads were assessed and statistics of data were plotted by the ReadStat.4 python script. The datasets can be used to profile the transcriptomic landscape of RNA viruses, provide information for novel gene annotations, can serve as resource for studying the virus-host interactions, and for the analysis of RNA base modifications. These datasets can be used to compare the different sequencing techniques, library preparation approaches, bioinformatics pipelines, and to analyze the RNA profiles of viruses with small RNA genomes.

Common Symptom, Rare Etiology: A Case Metastatic Cancers of Unknown Primary Origin Presenting with Epistaxis and Gingival Bleeding

Introduction: Epistaxis and gingival bleeding are among the most common presentation to the emergency department for patients with thrombocytopenia. Here, we present a case who was admitted to the emergency department with thrombocytopenia and was diagnosed with metastatic cancer of unknown primary origin. Case Report: A 26-year-old male patient was admitted to the emergency department with gingival bleeding and epistaxis. The body temperature was 38.3 °C. Petechial rash, ecchymosis or organomegaly was not detected on physical examination. Laboratory results revealed thrombocytopenia as 31 × 103 (159-388 × 103/μL). Although hemoglobin and leukocyte counts were normal, no band or precursor cell was observed in the patient's peripheral blood smear. There was no history of weight loss, night sweats, arthritis, malar rash, photosensitivity, contact with ticks, animals, or a COVID-19 patient. Serological tests performed for infections such as HIV, EBV, HCV, Crimean-Congo hemorrhagic fever were negative. Bone marrow biopsy was performed due to the unexplained cytopenia, reported as "signet ring cell metastatic adenocarcinoma". Gastrointestinal system endoscopy was performed to detect primary cancer. A biopsy was taken from the antrum and corpus revealed gastritis. An FDG PET-CT was revealed heterogeneously pathologically increased FDG attitude in all axial and appendicular bones. Despite all the modalities of diagnosis, the origin was not found and the patient was transferred to the oncology department for treatment with a diagnosis of cancer of unknown origin with bone marrow infiltration. Conclusion: Bone marrow metastases should be kept in mind in patients presenting with thrombocytopenia.